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Oncology - Malignant Bowel Obstruction - Fast Facts | NEJM Resident 360

Malignant bowel obstruction (MBO), especially of abdominal or gynecological origin, is common in patients with advanced cancer. MBO is defined as:

• clinical evidence of bowel obstruction

• obstruction distal to the Treitz ligament

• the presence of primary intra-abdominal or extra-abdominal cancer with peritoneal involvement

• the absence of reasonable possibilities for a cure.

Symptoms

Diagnostic Workup

• Plain abdominal radiograph is sensitive for high-grade obstruction and is quick and easily accessible.

• Contrast-enhanced abdominal CT can detect low-grade obstructions as well as quantitate disease burden and other clinical factors (e.g., bowel ischemia).

• Routine bloodwork can rule out metabolic derangement (electrolytes, extended electrolytes); include CBC, lactate, and renal function.

Management

• palliative surgery (e.g., intestinal bypass, lysis of adhesions, removal of tumor); often not feasible, especially if patient is malnourished, has peritoneal disease, or has multiple levels of obstruction

• endoscopic or interventional radiology procedures (e.g., stenting or placement of venting gastrostomy tubes)

• medical management: When the above interventions are not feasible, medical management can include the following:

  • bowel rest

  • nasogastric decompression (NGT)

  • total parenteral nutrition (TPN) — controversial and should be reserved for patients with a preserved general status, slow-growing tumors, the possibility of response to chemotherapy, and reasonable expectations of survival

  • adequate symptom management with analgesia and antiemetics (e.g., haldol); avoid prokinetic agents in cases of complete obstruction

    • opiates — do not avoid but note capacity to affect bowel motility

    • glucocorticoids — have antiemetic properties; may increase rate of spontaneous resolution of MBOs by reducing inflammation

    • antisecretory drugs (e.g., scopolamine, hyoscine butylbromide, and octreotide) to reduce intestinal hypersecretion; octreotide has been shown to have the greatest efficacy in controlled trials

    • decompressive percutaneous endoscopic gastrostomy in some patients for symptom management and palliation

Algorithm for Assessment and Management of MBO

(Reprinted from European Journal of Cancer, 44(8) 1105-1115, Ripamonte C et. al., Management of Malignant Bowel Obstruction. Copyright 2008, with permission from Elsevier.)

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